List all chronic medical conditions that you have (eg. diabetes, heart or lung conditions)

List all allergies that you have (eg. eggs, nuts, antibiotics)

If you have had a serious reaction to a vaccine in the past, which vaccine was it?

List all of your current medications (including oral contraception)

Have you recently suffered from any infection (e.g heavy cold, flu or high temperature)?

Yes

Does having an injection cause you to feel faint?

Yes

Do you or any close family members have epilepsy?

Yes

Do you have any history of mental illness including depression or anxiety?

Yes

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?

Yes

Have you taken out travel insurance?

Yes

If you have a medical condition, have you told your insurance company about it?

Yes

Are you pregnant, planning pregnancy or breast feeding?

Yes

Write below any further information that might be relevant

Vaccination History

Have you ever had any of the following vaccinations / tablets and if so, when?

Tetanus

Yes

Polio

Yes

Diphtheria

Yes

Typhoid

Yes

Hepatitis A

Yes

Hepatitis B

Yes

Meningitis

Yes

Yellow Fever

Yes

Influenza

Yes

Rabies

Yes

Jap B Enceph

Yes

Tick Borne

Yes

Malaria Tablets

Yes

Other

About This Form

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Personal Information

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